It's spring break week and my family has been traveling through Washington DC and Virginia, visiting family and sightseeing, predominantly at historical sites. This simultaneous emphasis on my own personal history while learning more about American history has reminded me of the importance of creating a narrative about one's life. By telling your own story, you often integrate separate parts of your life, creating a more coherent sense of self.
Integrating your experiences with infertility into your life narrative is an essential part of understanding how it has affected you. For example, as we drove through the area of the country my mother's ancestors lived, I found myself thinking about how in retrospect, past generations of my female relatives have also struggled with infertility, although it may not have been diagnosed or treated. I also found myself wondering how surprised (most likely pleasantly) my relatives might be to learn that a beautiful, self-possessed girl born in India was now a member of their family.
In addition to my own story, I also discovered another narrative of infertility in a place I didn't expect to find it. During our visit to Mount Vernon, George Washington's home, I heard repeated references to his raising of his wife's children and grandchildren (Martha was a widow when she met George and had two living children prior to their marriage). However, I didn't hear any mention of any children he and Martha had together. My "infertility antennae" went up, and so when we got to the hotel, I started Googling. Sure enough, it seems that George Washington himself most likely suffered from infertility. There was article published in Fertility and Sterility in 2004, which can be found here, which reports that George Washington was most likely infertile due to a prolonged infection with enteric tuberculosis. Like most men of his time, he blamed his infertility on his wife. However, it seems that Martha's prior history of four successful pregnancies suggests that George Washington's own fertility was most likely compromised. Further, the article describes evidence that George Washington had wished to have children and was saddened upon the realization that this probably would never happen for him. By all reports, he loved children and enjoyed the time he spent raising Martha's children and her grandchildren.
The article's author, John Amory, also speculated on how George Washington's infertility may have affected his professional career and the development of the United States. Did his disappointment about not having any children of his own fuel his ambition and resolve? Was George Washington more motivated to nurture talented young men, thus strengthening the new country and its emerging government, to fulfill some of his own parenting needs? Although we may never know for sure, it stands to reason that George Washington's infertility must have shaped his emotional and professional life in many ways. Freud's concept of sublimation, in which unfulfilled desires are channeled to more socially appropriate goals (or in this case perhaps goals that are possible to achieve) may be relevant here.
Interestingly, the author noted that in historical and medical discussions of George Washington's life, his lack of children and probable infertility is very rarely mentioned. He theorizes that some historians may feel that discussing his infertility might "lessen" his image. However, to me, it only makes George Washington an even more impressive person. He was able to accomplish incredible things and change the course of history, all while struggling with his own feelings about not being able to have his own children--a struggle that most readers of this blog know is a profound one. In addition to being a hero and a great leader, he also has provided us with a model of resilience and coping. Despite his bad luck with infertility, he led a successful, rewarding, and incredible life. In the end, I think that is the best outcome for which we can hope--regardless of our circumstances.
Thursday, March 31, 2011
Monday, March 21, 2011
Do feelings about infertility ever go away? Long-term psychological implications of infertility treatment
As an infertility therapist, I think the question that I am most commonly asked is whether or not the pain from infertility ever goes away. During those dark periods during infertility treatment, it can seem as if things are always going to feel as bad as they do at that moment.
I can always offer reassurance that things will indeed eventually feel better, but I cannot say with confidence that the pain of infertility goes away completely. In my experience, people do generally go on to resolve their infertility issues in one way or the other, and lead happy and rewarding lives. Even within those lives, however, there are moments in which the pain of infertility resurfaces. I will never forget feeling that familiar, bittersweet pain and envy upon hearing a friend was pregnant--except that I myself was actually pregnant at the time! It is almost as if the pain and envy had become a reflexive response, conditioned over the years. A few months of pregnancy had done nothing to extinguish it.
The above example highlights one of the ways feelings about infertility may reemerge--through exposure to familiar situations and cues. Certain dates, times of year, people, and places may all be evocative of painful experiences, events, or realizations. Although in retrospect such painful feelings are completely understandable, they often take people off-guard if they are not prepared for them.
Another time infertility-related feelings commonly resurface is during major life transitions. For example, perimenopause and menopause bring up feelings about reproduction for almost all women, but if there is a history of infertility there may be more intense feelings about closing this chapter in their life.
A history of infertility also is known to increase anxiety during pregnancy and parenthood. Because you have already experienced things not going according to plan, you become more aware of all the frightening, albeit relatively improbable, possibilities during pregnancy, childbirth, infancy and childhood. So many times, I have seen women who had repeatedly fantasied about how happy they would be once they were pregnant become overcome with anxiety once the long-awaited pregnancy occurred. Although this is a shame, I think in a certain way it's probably unavoidable given the types of infertility experiences they had endured.
Infertility is usually a profound, life-changing experience. Studies have shown it to be only slightly less traumatic than the death of a parent and on par with a divorce in terms of the stress it produces. As a striking example, I worked with a woman who experienced infertility, but then went on to have several children. Along the way, she encountered several difficulties. One of her children had a serious, but correctable medical condition. She herself experienced medical difficulties in which her own life was hanging in the balance for months. During this time, she also unfortunately experienced a great deal of interpersonal conflict and disappointment. When I asked her which one of these situations had been the most difficult, she answered without hesitation, "Infertility."
As a silver lining, I have found that each time feelings about infertility reemerge, it is an opportunity to work through them again. This can allow you to have more closure and to better understand your own experiences. With time and distance, you can see things more clearly, and may able to resolve some of the hurt feelings of the past.
So in sum, yes, it really does get better--a lot better! But when something this profound happens to us, we can't expect ourselves not to have feelings about it for a long time to come. However, those painful moments can often often contain the seeds of future psychological growth, and thus our lives may actually be enriched.
I can always offer reassurance that things will indeed eventually feel better, but I cannot say with confidence that the pain of infertility goes away completely. In my experience, people do generally go on to resolve their infertility issues in one way or the other, and lead happy and rewarding lives. Even within those lives, however, there are moments in which the pain of infertility resurfaces. I will never forget feeling that familiar, bittersweet pain and envy upon hearing a friend was pregnant--except that I myself was actually pregnant at the time! It is almost as if the pain and envy had become a reflexive response, conditioned over the years. A few months of pregnancy had done nothing to extinguish it.
The above example highlights one of the ways feelings about infertility may reemerge--through exposure to familiar situations and cues. Certain dates, times of year, people, and places may all be evocative of painful experiences, events, or realizations. Although in retrospect such painful feelings are completely understandable, they often take people off-guard if they are not prepared for them.
Another time infertility-related feelings commonly resurface is during major life transitions. For example, perimenopause and menopause bring up feelings about reproduction for almost all women, but if there is a history of infertility there may be more intense feelings about closing this chapter in their life.
A history of infertility also is known to increase anxiety during pregnancy and parenthood. Because you have already experienced things not going according to plan, you become more aware of all the frightening, albeit relatively improbable, possibilities during pregnancy, childbirth, infancy and childhood. So many times, I have seen women who had repeatedly fantasied about how happy they would be once they were pregnant become overcome with anxiety once the long-awaited pregnancy occurred. Although this is a shame, I think in a certain way it's probably unavoidable given the types of infertility experiences they had endured.
Infertility is usually a profound, life-changing experience. Studies have shown it to be only slightly less traumatic than the death of a parent and on par with a divorce in terms of the stress it produces. As a striking example, I worked with a woman who experienced infertility, but then went on to have several children. Along the way, she encountered several difficulties. One of her children had a serious, but correctable medical condition. She herself experienced medical difficulties in which her own life was hanging in the balance for months. During this time, she also unfortunately experienced a great deal of interpersonal conflict and disappointment. When I asked her which one of these situations had been the most difficult, she answered without hesitation, "Infertility."
As a silver lining, I have found that each time feelings about infertility reemerge, it is an opportunity to work through them again. This can allow you to have more closure and to better understand your own experiences. With time and distance, you can see things more clearly, and may able to resolve some of the hurt feelings of the past.
So in sum, yes, it really does get better--a lot better! But when something this profound happens to us, we can't expect ourselves not to have feelings about it for a long time to come. However, those painful moments can often often contain the seeds of future psychological growth, and thus our lives may actually be enriched.
Tuesday, March 15, 2011
Unpredictability
A few weeks ago, when I returned to my car after work, I found an unpleasant surprise. The passenger side window of the car was smashed in, and glass was everywhere. The contents of the car were tossed about. The thief had apparently tried, and failed, to steal the built in DVD player (although he/she did succeed in breaking it--so probably trying to steal one of those things is not a good idea). Nothing was stolen from the car in the end--not my electronic toll pass, not prepaid parking vouchers, not my daughter's wallet with all of her life savings in it. It did create, however, a big mess, an expense, $2800 worth of damage to the car, and some discomfort and work for me.
During my rather cold, windowless drive on the expressway to the repair shop, it struck me that this situation felt very similar to the realization that I was infertile. When I first arrived at my car, I was in a state of disbelief. Even though what had happened was obvious, my mind did not want to accept that someone had broken into the car. "Perhaps someone just accidentally bumped the window in a freak accident," I kept thinking. However, the preponderance of evidence to the contrary forced me to accept the fact that yes, I had just been robbed, and that yes, people can be not-so-nice sometimes. The latter is a fact that even though I know it is true intellectually, I have always struggled with accepting it emotionally. I think the same is true for my infertility. Even when a preponderance of evidence suggested I had big fertility problems, I could still entertain the fantasy of somehow miraculously getting pregnant anyway--which obviously never happened, and isn't going to happen, either. I think it's taken me over a decade to accept that fact--and as those who know me can attest, I am not exactly Suzy Sunshine. Optimism is not my game. I am not a denial-prone person, and could probably use a little more denial in my life. So if even I have struggled long and hard with accepting the finality of my infertility, I think it has to be a pretty common-place event among those who naturally have a sunnier outlook.
Another facet of the break-in situation that felt similar to infertility is that it created a lot of work, delays, and expense. Despite my medical problems, I am lucky to have two wonderful children. However, those children were not easy to come by--both the adoption and IVF journeys they required involved a lot of hard work, physical discomfort and suffering, time, and money. Just like the car, it was doable. It wasn't the end of the world--but it did require marshaling a lot of energy and resources that could have gone to other things, I suppose--like my career, or learning to cook food without burning everything. But we must play the cards we are dealt, and placed in the same situations again, I would make the same choices again, even though they required hardship and sacrifice.
Once I accepted that my car was burglarized, I realized I needed some help--because I had no idea how exactly to manage the situation. I tromped to the parking garage office and told the lady working there what had happened. She sprang into action, filling out forms, and letting me use her phone to make the police report. Two other garage employees worked for a long time in the freezing cold to clean the glass out of my car. The worked endlessly on taping garbage bags to the window, which was an incredibly sweet gesture even though it blew off as soon as I had to drive 30 mph. They all introduced themselves, hugged me, and told me to come by and visit them every week at the office--they were going to "take care of me". They were all such lovely people, and I never would have met them otherwise. To be shown such kindness, after experiencing some of the less desirable parts of human nature, was wonderful. That struck me as the other thing that is reminiscent of my infertility. Because my infertility happened, I have had the good fortune to meet and work with wonderful people whom otherwise I would never have known. I include my blog readers among this list--it's been a pleasure to read your comments and blogs and get to know you a little bit.
Okay, so maybe that doesn't completely make up for getting your window smashed in, literally or metaphorically. But it really does help soften the blow.
Now, if I could just get my car back from the repair shop.....
During my rather cold, windowless drive on the expressway to the repair shop, it struck me that this situation felt very similar to the realization that I was infertile. When I first arrived at my car, I was in a state of disbelief. Even though what had happened was obvious, my mind did not want to accept that someone had broken into the car. "Perhaps someone just accidentally bumped the window in a freak accident," I kept thinking. However, the preponderance of evidence to the contrary forced me to accept the fact that yes, I had just been robbed, and that yes, people can be not-so-nice sometimes. The latter is a fact that even though I know it is true intellectually, I have always struggled with accepting it emotionally. I think the same is true for my infertility. Even when a preponderance of evidence suggested I had big fertility problems, I could still entertain the fantasy of somehow miraculously getting pregnant anyway--which obviously never happened, and isn't going to happen, either. I think it's taken me over a decade to accept that fact--and as those who know me can attest, I am not exactly Suzy Sunshine. Optimism is not my game. I am not a denial-prone person, and could probably use a little more denial in my life. So if even I have struggled long and hard with accepting the finality of my infertility, I think it has to be a pretty common-place event among those who naturally have a sunnier outlook.
Another facet of the break-in situation that felt similar to infertility is that it created a lot of work, delays, and expense. Despite my medical problems, I am lucky to have two wonderful children. However, those children were not easy to come by--both the adoption and IVF journeys they required involved a lot of hard work, physical discomfort and suffering, time, and money. Just like the car, it was doable. It wasn't the end of the world--but it did require marshaling a lot of energy and resources that could have gone to other things, I suppose--like my career, or learning to cook food without burning everything. But we must play the cards we are dealt, and placed in the same situations again, I would make the same choices again, even though they required hardship and sacrifice.
Once I accepted that my car was burglarized, I realized I needed some help--because I had no idea how exactly to manage the situation. I tromped to the parking garage office and told the lady working there what had happened. She sprang into action, filling out forms, and letting me use her phone to make the police report. Two other garage employees worked for a long time in the freezing cold to clean the glass out of my car. The worked endlessly on taping garbage bags to the window, which was an incredibly sweet gesture even though it blew off as soon as I had to drive 30 mph. They all introduced themselves, hugged me, and told me to come by and visit them every week at the office--they were going to "take care of me". They were all such lovely people, and I never would have met them otherwise. To be shown such kindness, after experiencing some of the less desirable parts of human nature, was wonderful. That struck me as the other thing that is reminiscent of my infertility. Because my infertility happened, I have had the good fortune to meet and work with wonderful people whom otherwise I would never have known. I include my blog readers among this list--it's been a pleasure to read your comments and blogs and get to know you a little bit.
Okay, so maybe that doesn't completely make up for getting your window smashed in, literally or metaphorically. But it really does help soften the blow.
Now, if I could just get my car back from the repair shop.....
Thursday, March 3, 2011
Can psychological support groups really double your chance of conception during infertiity treatment?
My father was in town last weekend, and was very excited about a clip he had recently seen on the Today show about infertility, which can be found here. He was very impressed to learn that if a woman participates in an infertility-related social support group, it doubles her chance of conception in a given treatment cycle. When I expressed skepticism, he was adamant. "They proved it at Harvard," he exclaimed! How could I argue with that?
And really, why would I want to argue with that? No one would like to believe that providing people with emotional support would fix their infertility problems more than me. Not only is this a problem I could actually do something about, but given my line of work, it would be financially lucrative if this were true. And yet, I had a sinking suspicion that unfortunately, this was just too good to be true.
Thus, I took myself took a look at the study referred to in the Today show interview. (For those of you who are interested, here is the citation: Domar, A. Clapp, D.,Slawsby, E., Dusek, J., Kessel, B., Freizinger, M., (2000). Impact of group psychological interventions on pregnancy rates in infertile women: Presented at the Annual Meeting of the American Society of Reproductive Medicine, October 5, 1998, San Francisco, California. Fertility and Sterility, Vol. 73 (4), 805-811.) And indeed, the study was performed at Harvard Medical School. The lead author, Alice Domar, Ph.D., is a very well-known psychologist in the area of infertility. And yes, the results did show the women who participated in one of two types of support groups had a conception rate of 54 and 55 percent, respectively, versus only 20 percent in the control group.
However, as is so often the case with psychological research, the results are not the whole story. As the authors of the study themselves explain, this study had some serious methodological issues that call into question the veracity and applicability of its results. The researchers had difficulty recruiting subjects for the study, and thus the sample size involved was very small--too small to conduct powerful statistical analyses or to make sweeping generalizations to the population in general. The researchers made no attempt to control for the type of diagnoses with with the women in the study were struggling--so there was no way to tell whether or not the severity of the diagnosis was a factor in treatment success. Further, because they had difficulty recruiting enough subjects, the researchers were unable to randomly assign women into the three groups (cognitive-behavioral treatment, social support group, and no treatment). In addition, they had such large rate of dropout in the control group (which received the 20% success rate) they decided to not run any statistical analyses on the results because they would not be representative or accurate. The authors concluded that it may be that psychological interventions could increase pregnancy rates, but they could not definitively prove it on the basis of this study--further research was needed to clarify the issue. And by the way, further study has not uniformly supported this finding. Dr. Domar's later studies in this area have shown that while being in support groups or mind-body treatment may increase coping skills, quality of life, and a sense of well-being during infertility treatment, it does not appear to significantly increase, much less double, pregnancy rates.
Needless to say, none of the above limitations mentioned in the study were mentioned in the Today show interview. Rather, the results of this study were presented as Harvard-endorsed gold-plated facts. I don't think there was any malice in this, but rather a good dose of naivete. It does underscore, however, how you really can't believe everything you read, hear, or see on television. As infertility patients, it is imperative for us to all become educated consumers of research. That way, we can go to the studies ourselves and evaluate them critically in order to make the best treatment decisions possible. With the internet, scientific journals and studies are now easier to obtain than ever. Although I did take several research and statistics classes in graduate school, anyone can read and understand the author's descriptions of the problems with the study in question.
I must add that I am a big fan of support groups for infertility. I think that they can provide a great deal of information, camaraderie, and support and I would encourage everyone struggling with infertility to consider joining, creating, or leading one. I just don't think we can expect that in doing so, pregnancy rates among the group members will double. As I've said before, I have a sneaking suspicion that your reproductive system, unless under extremely stressful conditions, doesn't care too much about your unconscious conflicts or how you feel. That doesn't mean that you shouldn't care either, though--and that's where getting enough emotional support is so important, whether it helps you get pregnant or not.
And really, why would I want to argue with that? No one would like to believe that providing people with emotional support would fix their infertility problems more than me. Not only is this a problem I could actually do something about, but given my line of work, it would be financially lucrative if this were true. And yet, I had a sinking suspicion that unfortunately, this was just too good to be true.
Thus, I took myself took a look at the study referred to in the Today show interview. (For those of you who are interested, here is the citation: Domar, A. Clapp, D.,Slawsby, E., Dusek, J., Kessel, B., Freizinger, M., (2000). Impact of group psychological interventions on pregnancy rates in infertile women: Presented at the Annual Meeting of the American Society of Reproductive Medicine, October 5, 1998, San Francisco, California. Fertility and Sterility, Vol. 73 (4), 805-811.) And indeed, the study was performed at Harvard Medical School. The lead author, Alice Domar, Ph.D., is a very well-known psychologist in the area of infertility. And yes, the results did show the women who participated in one of two types of support groups had a conception rate of 54 and 55 percent, respectively, versus only 20 percent in the control group.
However, as is so often the case with psychological research, the results are not the whole story. As the authors of the study themselves explain, this study had some serious methodological issues that call into question the veracity and applicability of its results. The researchers had difficulty recruiting subjects for the study, and thus the sample size involved was very small--too small to conduct powerful statistical analyses or to make sweeping generalizations to the population in general. The researchers made no attempt to control for the type of diagnoses with with the women in the study were struggling--so there was no way to tell whether or not the severity of the diagnosis was a factor in treatment success. Further, because they had difficulty recruiting enough subjects, the researchers were unable to randomly assign women into the three groups (cognitive-behavioral treatment, social support group, and no treatment). In addition, they had such large rate of dropout in the control group (which received the 20% success rate) they decided to not run any statistical analyses on the results because they would not be representative or accurate. The authors concluded that it may be that psychological interventions could increase pregnancy rates, but they could not definitively prove it on the basis of this study--further research was needed to clarify the issue. And by the way, further study has not uniformly supported this finding. Dr. Domar's later studies in this area have shown that while being in support groups or mind-body treatment may increase coping skills, quality of life, and a sense of well-being during infertility treatment, it does not appear to significantly increase, much less double, pregnancy rates.
Needless to say, none of the above limitations mentioned in the study were mentioned in the Today show interview. Rather, the results of this study were presented as Harvard-endorsed gold-plated facts. I don't think there was any malice in this, but rather a good dose of naivete. It does underscore, however, how you really can't believe everything you read, hear, or see on television. As infertility patients, it is imperative for us to all become educated consumers of research. That way, we can go to the studies ourselves and evaluate them critically in order to make the best treatment decisions possible. With the internet, scientific journals and studies are now easier to obtain than ever. Although I did take several research and statistics classes in graduate school, anyone can read and understand the author's descriptions of the problems with the study in question.
I must add that I am a big fan of support groups for infertility. I think that they can provide a great deal of information, camaraderie, and support and I would encourage everyone struggling with infertility to consider joining, creating, or leading one. I just don't think we can expect that in doing so, pregnancy rates among the group members will double. As I've said before, I have a sneaking suspicion that your reproductive system, unless under extremely stressful conditions, doesn't care too much about your unconscious conflicts or how you feel. That doesn't mean that you shouldn't care either, though--and that's where getting enough emotional support is so important, whether it helps you get pregnant or not.
Thursday, February 24, 2011
The role of anxiety in infertility treatment
Anxiety is an unavoidable part of infertility treatment, and it is probably one of the main reasons that the process often is so traumatizing. After all, there are so many opportunities for worry during every treatment cycle, from successfully being cleared to begin treatment, response during treatment, embryo fertilization and survival, and of course, the outcome of the pregnancy test. Many of these things are out of our realm of control, and worrying about how it will all turn out is sometimes all we have left to "do". In addition, treatment cycles usually stretch out over a month or more, with long periods of time in which we must simply wait to get more information. Thus, much of the time, we look at the anxiety we experience during infertility treatment as something we must manage and work around, rather than something to which we need to directly respond.
However, there are times when anxiety can play a positive role in infertility treatment. Anxiety can function as an important signal that there is something in the situation that is not safe or good for us. In such cases, if we don't respond to our anxiety, we can be missing opportunities to improve our situation.
From an evolutionary perspective, anxiety functions as a protective mechanism. Because we must take in a large amount of information from our environment quickly, we often respond to threats on an emotional, rather than a cognitive basis. As soon as a threat is perceived, our emotional response of anxiety and fear, such as "Oh no! Hungry tiger over there!" quickly helps our bodies respond to the situation, providing the energy to do what must be done to ensure our survival (in this case, running away).
Although most of us no longer spend lots of time in the jungle keeping our eyes out for tigers, the protective mechanism remains the same. Thus, if during the course of your infertility treatment, you suddenly find yourself experiencing intense anxiety, I think it is important to take some time to figure out why. Did something just happen with your treatment that you found concerning, even if your doctor or nurse didn't? If so, it may be important to investigate this further--it has been my experience that even the best of medical professionals can occasionally miss a detail that might turn out to be very important in the case. For example, a friend of mine became anxious during her IVF cycle when she noticed that the time of retrieval, her lining was only 5.5 mm. She raised this issue with her RE, but he wasn't concerned about her lining and did the transfer anyway, which resulted in a chemical pregnancy. Her anxiety about her lining persisted, and she decided to get a second opinion. During that consultation, the new RE agreed with her concerns about her lining. As she pursued treatment with him, it turned out that she indeed had huge lining problems--causing her cycle to be canceled twice until they finally figured out the winning combination of medications to get her lining to the proper thickness. However, once her lining was good, she was able to get pregnant and carry her baby to term.
I think another important type of anxiety that often goes overlooked is rooted in the physical, body sensations that women often have during infertility treatment. Although I think most doctors don't put much stock in these perceptions, I have found that women who are infertility treatment tend to be so aware of their bodies they can often tell that something is awry before it appears in lab results or on a medical exam. For instance, they may be able to discern that their bodies aren't responding to medication in the desired way. Also, on several occasions I have observed that women have been able to sense when an early pregnancy isn't going well, even before their HCG levels start dropping. If you are in treatment and you have anxiety due to the persistent sense that your body is just not feeling right, I would encourage you to report that to your doctor and investigate it further if need be.
In sum, although anxiety during infertility treatment is usually never pleasant, it can sometimes provide us with useful information. Learning to discern whether or not an anxiety signal is a response to a potentially threatening situation, or whether it is in response to merely feeling out of control, is an important aspect of managing--and surviving--infertility treatment.
However, there are times when anxiety can play a positive role in infertility treatment. Anxiety can function as an important signal that there is something in the situation that is not safe or good for us. In such cases, if we don't respond to our anxiety, we can be missing opportunities to improve our situation.
From an evolutionary perspective, anxiety functions as a protective mechanism. Because we must take in a large amount of information from our environment quickly, we often respond to threats on an emotional, rather than a cognitive basis. As soon as a threat is perceived, our emotional response of anxiety and fear, such as "Oh no! Hungry tiger over there!" quickly helps our bodies respond to the situation, providing the energy to do what must be done to ensure our survival (in this case, running away).
Although most of us no longer spend lots of time in the jungle keeping our eyes out for tigers, the protective mechanism remains the same. Thus, if during the course of your infertility treatment, you suddenly find yourself experiencing intense anxiety, I think it is important to take some time to figure out why. Did something just happen with your treatment that you found concerning, even if your doctor or nurse didn't? If so, it may be important to investigate this further--it has been my experience that even the best of medical professionals can occasionally miss a detail that might turn out to be very important in the case. For example, a friend of mine became anxious during her IVF cycle when she noticed that the time of retrieval, her lining was only 5.5 mm. She raised this issue with her RE, but he wasn't concerned about her lining and did the transfer anyway, which resulted in a chemical pregnancy. Her anxiety about her lining persisted, and she decided to get a second opinion. During that consultation, the new RE agreed with her concerns about her lining. As she pursued treatment with him, it turned out that she indeed had huge lining problems--causing her cycle to be canceled twice until they finally figured out the winning combination of medications to get her lining to the proper thickness. However, once her lining was good, she was able to get pregnant and carry her baby to term.
I think another important type of anxiety that often goes overlooked is rooted in the physical, body sensations that women often have during infertility treatment. Although I think most doctors don't put much stock in these perceptions, I have found that women who are infertility treatment tend to be so aware of their bodies they can often tell that something is awry before it appears in lab results or on a medical exam. For instance, they may be able to discern that their bodies aren't responding to medication in the desired way. Also, on several occasions I have observed that women have been able to sense when an early pregnancy isn't going well, even before their HCG levels start dropping. If you are in treatment and you have anxiety due to the persistent sense that your body is just not feeling right, I would encourage you to report that to your doctor and investigate it further if need be.
In sum, although anxiety during infertility treatment is usually never pleasant, it can sometimes provide us with useful information. Learning to discern whether or not an anxiety signal is a response to a potentially threatening situation, or whether it is in response to merely feeling out of control, is an important aspect of managing--and surviving--infertility treatment.
Thursday, February 17, 2011
Disclosure and secrets in infertility treatment: or how I became a sneaky liar
Some weeks ago, a few readers asked me to discuss the topic of disclosure in infertility treatment. This is an extremely important topic, and yet I have found myself procrastinating in terms of writing about it. I think this is because I myself have struggled with the decision of how much, and to whom, to reveal about my infertility treatments and decisions. With both disclosure and secrecy, problems arise, making a clear-cut choice between the two options difficult at best.
As I have written about previously here, I was actively involved infertility treatment for several years before we adopted our older daughter, and then again a few years later.
When I was first diagnosed with infertility, I was fairly open with my friends and coworkers about my situation. The decision to do so was concordant with my personality and outlook on life in general—I have always lived my life as an “open book”. At first, it was great, as I could talk about my infertility whenever I wanted to, and I had lots of support from the people around me. However, as things began to drag on, and treatment cycle after treatment cycle failed, I started to regret my decision to be open. It felt like it was my responsibility to inform the many interested parties that my cycle had failed—again. Each time it happened, I dreaded this process of going down the list and making those calls (no Twitter back in those days!) more and more. After my first miscarriage, these calls were downright excruciating. Further, as my friends and coworkers were predominantly women in their late twenties and early thirties, they were all starting to get pregnant. Consequently, many worries and discussions about how to tell “poor Lisa” the news ensued. Sometimes I would hear about their pregnancies through the grapevine, sometimes I would guess, and sometimes I would be told directly--occasionally with kindness and finesse, but often not. As you would probably expect, after a certain point, I had difficulty coping with this situation, and I withdrew from many people who were otherwise lovely friends and acquaintances.
Years later, when after adopting, I decided to return to infertility treatment, I knew I had to do things differently. So this time, I decided to consciously limit the number of people I told about my plans to two close friends, and my parents, and my brother and his wife. If I didn’t absolutely need the emotional support and/or instrumental help of the person involved, I didn’t tell them. I thought that this would protect me from having to provide disappointing news again. In addition, I wouldn’t have to hear others' opinions, informed or not, about my treatment decisions. As I already had an adopted daughter, no one suspected that I would be crazy enough to try infertility treatment again—so I didn’t get many questions, either.
I was surprised to find that not disclosing what was going on with me was more difficult than I had anticipated. To prepare for my treatment, I had to do a two-month course of Lupron Depot, which threw my body into sudden and severe menopause. I was sweating, forgetful, and miserable, but I couldn’t really tell anyone that—so I had to make creative excuses about why I kept turning red all the time. On occasion, I found myself telling lies about where I had been, or why I couldn’t do certain activities. But perhaps more significantly, I found that if I wasn’t able to talk about what was really going on with me, I basically felt I had nothing to say to people about myself. I didn’t feel good about lying to people, and I didn’t trust myself not to slip some detail into the conversation that would only make sense if you knew the whole story. I felt tongue-tied and I’m sure others noticed my awkwardness. Thus, I became somewhat withdrawn again, from an equally lovely group of friends and acquaintances.
This reticence continued into my pregnancy, when well into the second trimester I found it difficult to disclose that I finally was pregnant. When my precocious young daughter figured out what was going on, she had no such qualms though, and her first step was to share the news at her preschool’s Show and Tell day—and thus I was “outed”. Of course it didn’t help that no one believed that it was possible, so both my daughter and I were met with shock and incredulity at these disclosures. One colleague of mine heard that I was pregnant through a mutual client, and refused to believe him, instead calling me in a panic because he was concerned that our client had suddenly become psychotic.
My withdrawal and reticence began to have a negative impact on my relationships. Several people were hurt that I hadn’t told them what I was going through, or informed them sooner about my pregnancy. I am fortunate that after I explained to them what had happened to me regarding disclosure in my first years of infertility treatment, they all forgave me. To be honest though, one of those friendships really never did recover, and I still feel sad about this.
In sum, I am not sure which was the best approach—telling, or not telling. I don’t think there is a “right answer” when it comes to disclosure. Rather, I think you have to pick your poison—is it more important to you to feel like you can be honest with those in your lives? Or does it feel more important to protect yourself from the reactions and emotions of others regarding your infertility treatment? If you don’t tell people what is going on, will you have other ways of getting the emotional support you need to survive the stress of infertility treatment? If you do, and they don’t handle this information well, will your relationships be able to weather the storm?
As you can see, I’m afraid I have more questions than answers when it comes to the issue of disclosure in infertility treatment. I’d love to hear your thoughts and experiences, and as always, if you have any questions or suggestions, please let me know. Thank you for reading!
As I have written about previously here, I was actively involved infertility treatment for several years before we adopted our older daughter, and then again a few years later.
When I was first diagnosed with infertility, I was fairly open with my friends and coworkers about my situation. The decision to do so was concordant with my personality and outlook on life in general—I have always lived my life as an “open book”. At first, it was great, as I could talk about my infertility whenever I wanted to, and I had lots of support from the people around me. However, as things began to drag on, and treatment cycle after treatment cycle failed, I started to regret my decision to be open. It felt like it was my responsibility to inform the many interested parties that my cycle had failed—again. Each time it happened, I dreaded this process of going down the list and making those calls (no Twitter back in those days!) more and more. After my first miscarriage, these calls were downright excruciating. Further, as my friends and coworkers were predominantly women in their late twenties and early thirties, they were all starting to get pregnant. Consequently, many worries and discussions about how to tell “poor Lisa” the news ensued. Sometimes I would hear about their pregnancies through the grapevine, sometimes I would guess, and sometimes I would be told directly--occasionally with kindness and finesse, but often not. As you would probably expect, after a certain point, I had difficulty coping with this situation, and I withdrew from many people who were otherwise lovely friends and acquaintances.
Years later, when after adopting, I decided to return to infertility treatment, I knew I had to do things differently. So this time, I decided to consciously limit the number of people I told about my plans to two close friends, and my parents, and my brother and his wife. If I didn’t absolutely need the emotional support and/or instrumental help of the person involved, I didn’t tell them. I thought that this would protect me from having to provide disappointing news again. In addition, I wouldn’t have to hear others' opinions, informed or not, about my treatment decisions. As I already had an adopted daughter, no one suspected that I would be crazy enough to try infertility treatment again—so I didn’t get many questions, either.
I was surprised to find that not disclosing what was going on with me was more difficult than I had anticipated. To prepare for my treatment, I had to do a two-month course of Lupron Depot, which threw my body into sudden and severe menopause. I was sweating, forgetful, and miserable, but I couldn’t really tell anyone that—so I had to make creative excuses about why I kept turning red all the time. On occasion, I found myself telling lies about where I had been, or why I couldn’t do certain activities. But perhaps more significantly, I found that if I wasn’t able to talk about what was really going on with me, I basically felt I had nothing to say to people about myself. I didn’t feel good about lying to people, and I didn’t trust myself not to slip some detail into the conversation that would only make sense if you knew the whole story. I felt tongue-tied and I’m sure others noticed my awkwardness. Thus, I became somewhat withdrawn again, from an equally lovely group of friends and acquaintances.
This reticence continued into my pregnancy, when well into the second trimester I found it difficult to disclose that I finally was pregnant. When my precocious young daughter figured out what was going on, she had no such qualms though, and her first step was to share the news at her preschool’s Show and Tell day—and thus I was “outed”. Of course it didn’t help that no one believed that it was possible, so both my daughter and I were met with shock and incredulity at these disclosures. One colleague of mine heard that I was pregnant through a mutual client, and refused to believe him, instead calling me in a panic because he was concerned that our client had suddenly become psychotic.
My withdrawal and reticence began to have a negative impact on my relationships. Several people were hurt that I hadn’t told them what I was going through, or informed them sooner about my pregnancy. I am fortunate that after I explained to them what had happened to me regarding disclosure in my first years of infertility treatment, they all forgave me. To be honest though, one of those friendships really never did recover, and I still feel sad about this.
In sum, I am not sure which was the best approach—telling, or not telling. I don’t think there is a “right answer” when it comes to disclosure. Rather, I think you have to pick your poison—is it more important to you to feel like you can be honest with those in your lives? Or does it feel more important to protect yourself from the reactions and emotions of others regarding your infertility treatment? If you don’t tell people what is going on, will you have other ways of getting the emotional support you need to survive the stress of infertility treatment? If you do, and they don’t handle this information well, will your relationships be able to weather the storm?
As you can see, I’m afraid I have more questions than answers when it comes to the issue of disclosure in infertility treatment. I’d love to hear your thoughts and experiences, and as always, if you have any questions or suggestions, please let me know. Thank you for reading!
Thursday, February 10, 2011
To "POAS" or not to "POAS": psychological implications of home pregnancy tests in infertility treatment
As every person whose ever done an infertility treatment cycle knows, the two weeks spent waiting to see if it worked or not are often excruciating. For the woman involved, the constant self-monitoring of her physical sensations can be overwhelming. Was that a cramp? If so, was it a "good cramp" or a "bad one"? Are my breasts hurting? Do they hurt more than yesterday? And what about that toe-itching? Does that mean anything? Add into the mix the fact that infertility medications usually taken during the two week wait, like progesterone, have their own slew of pregnancy-mimicking side effects, and that early pregnancy symptoms are themselves notoriously fickle, coming and going with no rhyme or reason--and you've got all the makings of a very stressful time.
Enter the home pregnancy test--loved by some, hated by others, and feared by most. Some women swear by them, saying that they give them the soonest possible information--good or bad. To these women, tolerating the anxiety of not knowing is so difficult that testing seems like the best option. Others regard them as "evil"--whom among us has not seen them referred to as the "evil pee stick" online? These women argue that "POASing' (peeing on a stick) can drive you crazy--test too early, and you've convinced yourself that you aren't pregnant when perhaps you are. If you test at the right time and get a negative result, it might be inaccurate. Regardless, even with a negative, you will still be hoping it is wrong, and then will be just as crushed when the clinic calls to say that your pregnancy test was negative. And regardless of what you feel about the idea of taking HPT's during a treatment cycle, we all share the experience that the few minutes it takes for the test results to appear are some of the longest-seeming minutes of our lives!
From a psychological perspective, is taking home pregnancy tests a good idea or a bad one during infertility treatment? To me, there isn't one right answer to that question. Rather, I think it depends on what I like to call your "defensive style"--the usual methods you use to cope with stress and anxiety.
When POASING may be helpful
If you tend to deal with stress by thinking about the stressful situation frequently, you are probably a person who, for better or worse, tends to experience your anxiety consciously. You may repeatedly go over the situation in your mind, trying to come up with a solution--even when there really isn't one sometimes. You may tend towards impatience, and dislike surprises or the feeling of being taken off guard. In this case, I think that you may find using home pregnancy tests (with a few caveats, listed below) will be helpful in managing your emotions during the two-week wait.
When POASING might not be for you
If you tend to deal with stress by focusing on things other than the stressful situation, and if you find thinking about or talking about them to be difficult, you may want to avoid home pregnancy tests. For you, they might just stir things up too much,causing you to feel unnecessarily traumatized. You may be better off dealing with the results, whatever they are, just once, when you hear them from the doctor's office.
If you are going to POAS--POAS "smart!"
If you find that you are the type of person who may want/need to use home pregnancy tests, I offer the following advice to minimize the chances of getting inaccurate information and the level of emotional turmoil involved. My first suggestion is that before you go to the drugstore or start running to the bathroom, you need to decide, in advance, what your POAS strategy will be for this cycle. What is more comfortable for you--testing as early as is feasible to get information as soon as possible, or waiting to make sure you don't get a false positive or negative? Figure this out, make a plan, and stick to it. Decide what day you might start testing, and how you will proceed depending on the type of results you get. Some women feel most comfortable waiting until the morning of their beta to test--others may prefer to start as soon as possible.
You also must promise yourself that no matter what the results are, you will not stop your medications, or stop following your doctor's orders, until your official test results come back--no matter how hopeless you feel the situation may be. Even if there is only a slim possibility that a home pregnancy test may be wrong, it still exists--and you don't want to have to live with lingering regrets about such a decision later in life.
If you are in the "start as soon as possible" camp, then keep in mind that if you took an HCG trigger shot, it can give you a false positive as the HCG remains in your system for several days until it washes out. So you probably need to wait at least 10-12 days from when you took your trigger shot to start testing. (Although, as a client of mine pointed out, you could POAS every day after the trigger shot, and wait for it to turn negative, and then if it starts turning positive again, you know you might be pregnant. While scientifically interesting, this method is definitely not for the feint of heart!)
Regardless of when or how often you decide to test, you should use a consistent method of urine collection and test administration in order to assure the most accuracy in the results. Take the test at the same time every day--most people find their first morning urine to have the highest concentration of HCG. If your urine isn't very concentrated, you may have to "hold it" for a while and test several hours later in order to get accurate results. Some women find peeing in a cup, and then holding the test stick in the cup for the number of seconds designated in the test instructions, to be more accurate.
Also, please be aware that different brands of pregnancy tests have different levels of sensitivity. If you are wanting an early result, you will probably need to buy one of the more sensitive tests. A list of tests and their HCG sensitivity levels can be found at several sites on the internet, including here.
Regardless of whatever strategy you choose, please keep in mind that a pregnancy test is just one piece of data from one point in time, and it may or may not tell the whole story. Like anything else in life, there are emotional risks involved in using them--but if you keep to your strategy, stay on your medications no matter what, you will hopefully find that there will be no lasting damage to your psyche.
Enter the home pregnancy test--loved by some, hated by others, and feared by most. Some women swear by them, saying that they give them the soonest possible information--good or bad. To these women, tolerating the anxiety of not knowing is so difficult that testing seems like the best option. Others regard them as "evil"--whom among us has not seen them referred to as the "evil pee stick" online? These women argue that "POASing' (peeing on a stick) can drive you crazy--test too early, and you've convinced yourself that you aren't pregnant when perhaps you are. If you test at the right time and get a negative result, it might be inaccurate. Regardless, even with a negative, you will still be hoping it is wrong, and then will be just as crushed when the clinic calls to say that your pregnancy test was negative. And regardless of what you feel about the idea of taking HPT's during a treatment cycle, we all share the experience that the few minutes it takes for the test results to appear are some of the longest-seeming minutes of our lives!
From a psychological perspective, is taking home pregnancy tests a good idea or a bad one during infertility treatment? To me, there isn't one right answer to that question. Rather, I think it depends on what I like to call your "defensive style"--the usual methods you use to cope with stress and anxiety.
When POASING may be helpful
If you tend to deal with stress by thinking about the stressful situation frequently, you are probably a person who, for better or worse, tends to experience your anxiety consciously. You may repeatedly go over the situation in your mind, trying to come up with a solution--even when there really isn't one sometimes. You may tend towards impatience, and dislike surprises or the feeling of being taken off guard. In this case, I think that you may find using home pregnancy tests (with a few caveats, listed below) will be helpful in managing your emotions during the two-week wait.
When POASING might not be for you
If you tend to deal with stress by focusing on things other than the stressful situation, and if you find thinking about or talking about them to be difficult, you may want to avoid home pregnancy tests. For you, they might just stir things up too much,causing you to feel unnecessarily traumatized. You may be better off dealing with the results, whatever they are, just once, when you hear them from the doctor's office.
If you are going to POAS--POAS "smart!"
If you find that you are the type of person who may want/need to use home pregnancy tests, I offer the following advice to minimize the chances of getting inaccurate information and the level of emotional turmoil involved. My first suggestion is that before you go to the drugstore or start running to the bathroom, you need to decide, in advance, what your POAS strategy will be for this cycle. What is more comfortable for you--testing as early as is feasible to get information as soon as possible, or waiting to make sure you don't get a false positive or negative? Figure this out, make a plan, and stick to it. Decide what day you might start testing, and how you will proceed depending on the type of results you get. Some women feel most comfortable waiting until the morning of their beta to test--others may prefer to start as soon as possible.
You also must promise yourself that no matter what the results are, you will not stop your medications, or stop following your doctor's orders, until your official test results come back--no matter how hopeless you feel the situation may be. Even if there is only a slim possibility that a home pregnancy test may be wrong, it still exists--and you don't want to have to live with lingering regrets about such a decision later in life.
If you are in the "start as soon as possible" camp, then keep in mind that if you took an HCG trigger shot, it can give you a false positive as the HCG remains in your system for several days until it washes out. So you probably need to wait at least 10-12 days from when you took your trigger shot to start testing. (Although, as a client of mine pointed out, you could POAS every day after the trigger shot, and wait for it to turn negative, and then if it starts turning positive again, you know you might be pregnant. While scientifically interesting, this method is definitely not for the feint of heart!)
Regardless of when or how often you decide to test, you should use a consistent method of urine collection and test administration in order to assure the most accuracy in the results. Take the test at the same time every day--most people find their first morning urine to have the highest concentration of HCG. If your urine isn't very concentrated, you may have to "hold it" for a while and test several hours later in order to get accurate results. Some women find peeing in a cup, and then holding the test stick in the cup for the number of seconds designated in the test instructions, to be more accurate.
Also, please be aware that different brands of pregnancy tests have different levels of sensitivity. If you are wanting an early result, you will probably need to buy one of the more sensitive tests. A list of tests and their HCG sensitivity levels can be found at several sites on the internet, including here.
Regardless of whatever strategy you choose, please keep in mind that a pregnancy test is just one piece of data from one point in time, and it may or may not tell the whole story. Like anything else in life, there are emotional risks involved in using them--but if you keep to your strategy, stay on your medications no matter what, you will hopefully find that there will be no lasting damage to your psyche.
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